1. Viral Hepatitis Andy King Consultant Gastroenterologist/Hepatologist
Birmingham Heartlands Hospital

3. HEPATITIS A Faeco-oral transmission Contaminated Food/Water
ALT often >1000
LFTs peak at one month after exposure
Self limiting
Fulminant in <1%, older, CLD
70% symptomatic
Nausea, vomiting, anorexia, fever, malaise
Jaundice in 40%
Jaundice resolves by 2 weeks
Complete recovery usual by 2-3 months
HEPATITIS A
Diagnosis : IgM HAV positive
(3-6 months)
IgG positive lifelong after exposure
Treatment Supportive
Care with Hepatotoxics

4. HAV Vaccination
Pre exposure Travellers to areas of high/intermediate prevalence CLD Haemophilia MSM IVDU
Post exposure
Contact of HAV infection
Outbreaks (local health protection team)

5. HEPATITIS E ALT +++, usually back to normal 1-6 weeks
Occasional prolonged cholestasis
Asia/Africa – contmainated water
Europe/America –porcine zoonosis
Diagnosis: IgM HEV positive, (5 months)
HEV RNA PCR but short viraemia
Self limiting
Most cases Asymptomatic
HEPATITIS E
Immunosuppressed/ CLD High Risk
Pregnancy / CLD – 25-75% Mortality
0.5-4% Liver Failure
Supportive Treatment
Possible role for Ribavirin

6. Hepatitis B Largely imported – Asia, Africa, E. Europe
Most infectious BBV (x100 more than HIV)

7. Hepatitis B Transmission
Endemic Countries
Vertical transmission (in utero, birth, breast feeding)
Early childood, close interpersonal contact
Unsterilised medical equipment UK
Unprotected penetrative sex
Sharing any drug equipment (not just needles)
Unsterilised tattoos/piercings
Needlestick
Rarely – toothbrush/razor
NOT contaminated food/water or casually in home/workplace

8. Serology OPD^ Hepatitis B HBsAg POSITIVE by EIA Hepatitis B HBsAg. Confirmed by Neutralisation Hepatitis B anti HBc POSITIVE by EIA Hepatitis B anti HBc IgM Negative by EIA Hepatitis B HBeAg Negative by EIA Hepatitis B anti HBe POSITIVE by EIA Hepatitis B Anti HBs Negative Hepatitis C Antibody Negative by EIA (Abbott) These results confirm previous findings. Please retest at 2-12 weeks after last exposure, for Hepatitis C if clinically indicated

10. + - Meaning Acute Infection Chronic Infection Cleared infection
Immunised
Healthy Carrier
HB core Antibody
Exposure + -
HB surface Antigen
Infection
HB surface Antibody
Immunity

11. c Ab
s Ag
s Ab + -

12. c Ab
s Ag
s Ab + -
c Ab
s Ag
s Ab + -

13. c Ab
s Ag
s Ab + -

14. c Ab
s Ag
s Ab + -
> 6 months

15. c Ab s Ag s Ab + - c Ab s Ag s Ab + -
> 6 months

16. c Ab s Ag s Ab + - c Ab s Ag s Ab + -
> 6 months

17. Immunised
c Ab
s Ag
s Ab - +

18. c Ab s Ag s Ab + - c Ab s Ag s Ab + - c Ab s Ag s Ab + - c Ab s Ag
Immunised
c Ab
s Ag
s Ab + -
c Ab
s Ag
s Ab - +
> 6 months

20. HBV Treatment
Liver Events
HCCa
Liver Mortality
Mortality

22. Reduced Risk Cirrhosis
HCCa
Mortality
Prevent Transmission

23. HBV Vaccination
Pre exposure Drug Users (partners and children) Sex workers Close family contact esp sexual Family adopting children from high prevalence area Regular blood products (eg haemophilia) CRF, CLD Travelling to areas of high prevalence Occupational risk
Immediate post exposure
Neonatal
Needlestick
(+/- Immunoglobulin)

24. Hepatitis C 200 million worldwide 3% worlds population
1.5 million deaths per year from HCV related liver disease
80% Acute HCV asymptomatic
80% become Chronic
Most common symptom = Fatigue

31. HCV Transmission Drug Users - ANY drug equipment
27% users had shared in last 6 months, lack of disclosure
Don’t forget anabolics, novel psychoactives, historical drug use even if only once
Piercings/tattoos/shaving – rarely from razors, nail clippers, toothbrushes
Vey low risk to household contacts
Vertical: approx 5%, breast feeding NOT contraindicated

32. HCV Transmission
Needlestick 1:50 risk from known HCV Sexual : uncommon but possible (0-2 per 1000 yrs) increased if coinfected HIV/STI or traumatic sex Transfusion :clotting factor<1987, blood <1991, transplant <1992 Medical/dental treatment in areas where HCV common and infection control poor - Pakistan, India, Africa, E Europe

33. - + Never Exposed Current Infection Spontaneous Clearance
Successful Treatment
Antibody - +
RNA
‘viral load’
Not needed
12 –
<12
Genotype
1-6

34. HCV Ab +
HCV RNA
Detectable

35. HCV Treatment
Mortality
Liver Mortality
HCCa
Liver Failure

40. Interferon 6 mo

41. Genotype 3, no cirrhosis, 8 weeks Genotype 3, cirrhosis, 12 weeks
2016…
100 % 97
100
100 75 50 25
144
ABT-493
+ ABT-530
ABT-493
+ ABT-530
ABT-493
+ ABT RBV
Genotype 3, no cirrhosis, 8 weeks
Genotype 3, cirrhosis, 12 weeks

42. 144

43. 144

47. Primary Care: Adults and children at increased risk of infection Migrants from medium or high prevalence countries Current or Past Drug Use Newly registered – ever used drugs? Hep B Testing AND Vaccination to those at Increased risk of infection Annual Hep C testing to those at Ongoing risk of infection

48. Public Health: Overall responsibility for Contact Tracing Advise and oversee other organisations to ensure surveillance and follow up of Hepatitis B and C eg GPs providing HBV vaccination and specialist referral

50. Questions?